M/S.NATCO PHARMA LTD.ess.natcopharma.co.in/files/scanco.pdfUNITED INDIA INSURANCE COMPANY LIMITED ... IRDA License no 005 ... Duly filled & signed Claim form by the employee with the

2/18/2016 1MDIndia Health Care Services ( TPA ) Pvt Ltd

M/S.NATCO PHARMA LTD.

UNITED INDIA INSURANCE COMPANY LIMITED

Policy No : 052100/28/15/P112796862 Policy Start Date-21/01/2016 Policy End Date –20/01/2017

Contents of Presentation

• Parties to Group Medi-claim Policy.

• Functions of MDIndia

• Scope of Mediclaim

• Terms & Condition for M/S.Natco Pharma Ltd

• Permanent policy exclusion

• How to avail Cashless Facility

• How to avail Re-imbursement Facility

• Checklist - Documents to be submitted for Re-imbursement

• Network of Hospitals for Cashless

• Website Access Navigation for Individual Employee

• Aneroid Mobile App Navigation – HAWK APP

• Toll free No. and mail ids –MDIndia Health Care Services (TPA) Pvt. Ltd.

MDIndia Health Care Services ( TPA ) Pvt Ltd2/18/2016 2

Group Mediclaim Policy In

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MD India Healthcare Services Pvt Ltd

• MDIndia Healthcare Service (TPA) Pvt. Ltd. was formed in November 2000, a licensed third Party Administrator (License No. 005) and were very soon a leading company in the insurance sector. The success of the Company has been built year on year by an ability to anticipate the future requirements of the Health insurance industry.

• Awarded : 2013 – The Indian Insurance Awards: Best TPA Award

• 2014 – The Indian Insurance Awards: Best TPA Award

• 2014 - 18th Asia Insurance Industry Awards: Service Provider of the Year

• 2015 – The Indian Insurance Awards: Innovative TPA of the Year


http://www.asiainsurancereview.com/asiaawards/winners

http://www.asiainsurancereview.com/asiaawards/winners

5

Transparent communication

Reliable processing TATs

Error free processing

Response timeframes & quality

Accessibility

Reach

Claim Cost Control

Coordination with Insurance company & Broker

Exceptional calls to be taken

Hassle free hospitalization

Policy understanding

Strategic Guidance

Value adds

What would you look for in a service provider

Founded in November 2000

IRDA License no 005

Headquartered in Pune, Maharashtra

One of the leading companies in the Health

Insurance sector of India

The Largest TPA in India by Revenue, Lives

Serviced, Claims Settled & Headcount

FYE 2013 Projected : 1st TPA to breach 100

Cr Revenue Mark

Pan India footprint with 115 Servicing

locations

In-House Developed Software deployed with

54 member strong team

3500+ Employees strong consisting of 500+

Medico’s on pay roll as full-time employees

with core team of MBBS, MD/MS

Specialists & MCh Surgeons

ISO, CRISIL & QCI certified

24x7 Customer Care and Support and

Website Services

6000+ Net work Hospitals

MDINDIA AT A GLANCE…..2016

MDIndia Health Care Services ( TPA ) Pvt Ltd2/18/2016

To work as a Nodal agency between Insurance Company, Natco Pharma Ltd, and the

Hospitals.

To issue ID Cards to all the members covered under the policy.

To administer Cashless Facility in network hospitals & reimbursement claims settlement as

per the policy terms and conditions.

To negotiate & procure comprehensive schedule of charges from empanelled hospitals.

Functions of MD India (TPA)


Scope of Mediclaim

• COVERAGE - Any Insured Person who shall contract any disease /illness or sustainany bodily injury through accident and upon the advice of a duly qualified doctorfor Hospitalisation in any Hospital in India .

• ROOM RENT ELIGILIBITY – Includes Room, boarding and nursing expenses

• Normal Room Max Limit–1.5% Per day.

• ICU Room Max Limit – 3% Per day.

• (This also includes Nursing Care, RMO & DMO Charges, IV Fluids/ BloodTransfusion Charges /Injection Administration Charges and similar expenses)

• HOSPITALISATION - Means admission in any Hospital/Nursing Home in India uponthe written advice of a Medical Practitioner for a minimum period of 24consecutive hours.

• PRE HOSPITALISATION medical charges up to 30 days period immediately beforethe Insured’s admission to hospital for that illness or injury.

• POST HOSPITALISATION medical charges up to 60 days period immediately afterthe Insured’s discharge from the hospital for that illness or injury.


Terms & Conditions for Natco Pharma Policy.

• POLICY COVERS: 1+5 (Self, Spouse, 2 Dependent Childrens and 2 parents or In-laws)

• SUM INSURED –Rs:200000/- per family.

• PRE-EXISTING DISEASES COVERAGE: Waived Off

4.1: Pre-Existing Illness/ Ailments are waived Off.

4.2: 30 Days lock in period waived off for any claim.

4.3: 1Yr/2Yr/3Yr/4Yr Exclusion waiting period waived Off.

• AMBULANCE CHARGES:1% of SI


Terms & Conditions for Natco Pharma Ltd.

• Cataract, Hernia, Hysterctomy Limits: Actual expenses incurred or 25% of the Sum insured whichever is less.

• Major Surgeries: Actual expenses incurred or 70% of the sum insured whichever is less.

• Claim intimation to be given within 48 Hrs. from date of admission

• Claim submission to be done within 15 days from date of discharge.

• Cheque in Favour of:• Reimbursement claim payment should be in favour of Employee.


The Insurance Company shall not be liable to make any payment under this Policy in respect ofany expenses whatsoever incurred by any Insured Person in connection with or in respect of:

1. Any Out Patient Charges/ OPD Treatment.

2. The cost of spectacles, contact lenses and hearing aids, external durable items.

3. Dental treatment or surgery of any kind unless requiring hospitalization.

4. Convalescence, general debility, a ‘run-down’ condition or rest cure, external congenitaldisease, defects or anomalies, sterility, venereal disease or intentional self injury.

5. All expenses arising out of any condition directly or indirectly caused by or associated withHuman T-Cell Lymphotropic Virus Type III (HTLB-III) or Lymphadenopathy Associated Virus(LAV) or the Mutants Derivative or variations of Deficiency Syndrome or any syndrome orcondition of a similar kind commonly referred to as AIDS. (Information available in the PolicySummary booklet)

6. Sex change or any treatment which results from, or is in any way related to, sex change.Hormone replacement therapy.

7. The treatment of psychiatric, mental or nervous conditions and insanity.

8. Any cosmetic, plastic surgery, aesthetic or related treatment of any description, whether ornot for psychological reasons, unless medically necessary as a result of an accident.

POLICY EXCLUSIONS


9. Any treatment received in convalescent homes, convalescent hospitals, health - hydros, Nature Cure clinics or similar establishments.

10. Any stay in hospital for any domestic reason or where there is no active, regular treatment by a specialist.

11. Any treatment received outside India.

12. Complication of surgery, therapy or treatment administered on the Insured Person which isnot prescribed or required by a Registered Medical Practitioner/ Registered MedicalInstitution in their professional capacity.

13. Taking of drugs unless it is taken on proper medical advice and is not for the treatment ofdrug addiction.

14. Any fertility, sub-fertility or assisted conception operation.

15. Any person whilst engaging in speed contest or racing of any kind (other than on foot),bungee jumping, parasailing, ballooning, parachuting, skydiving, paragliding, hang gliding,mountain or rock climbing necessitating the use of guides and ropes, pot holing, abseiling,deep sea diving using hard helmet and breathing apparatus, polo, snow and ice sports andactivities and similar hazards.

16. Any person whilst engaging in aviation, whilst mounting into or demounting from ortraveling in any aircraft other than as a passenger (fare paying or otherwise) in any dulylicensed standard type of aircraft anywhere in the world*.

POLICY EXCLUSIONS


• Cashless Facility is available at Network Hospitals, provided the purpose of Hospitalisation iswithin the scope of cover and adherence to protocol.

The patient need to bring Mediclaim ID card along with any valid Photo ID card (e.g.-Voter ID, Passport, PAN card, Driving Licence, School or College ID card etc.), during admission to Hospitalisation.

Hospital will send RAL & related documents to TPA (MD India)

If Cashless is accorded, TPA will inform the member and the hospital on the same & will send a letter of approval (Authorisation Letter) to Hospital, for CASHLESS facility. Similar Procedure is followed after Discharge is confirmed.

In case of further clarifications, MD India will contact employee/HR.

TPA will examine the documents, if the ailment is covered under the policy, they will ACCORD a Cashless facility to the member.

Claim Process – CASHLESS


In case of a medical claim where the member has already paid or intends to pay the

hospital bill, then the following process should be followed –

Intimate to TPA 48 hrs. prior to admissionPay the Hospital bill

Complete the claim form. Attach all the original documents & submit the same to MD India Helpdesk / respective HR Person.

The complete set is forwarded to TPA (MD India) within 15 days from the Date of Discharge from the Hospital.

If the claim is payable, payment will be forwarded to the respective Employee Account.

In case of further clarifications, MD India will contact employee/HR

TPA will lodge a claim with the Insurance Company after verifying the documents.

Claim Process – REIMBURSEMENT


1. Duly filled & signed Claim form by the employee with the seal & signature of the concerned authority in the organization.

2. Photocopy of Cashless card.3. Original Discharge card / Discharge summary.4. Original Hospital bill with the seal & signature of the Hospital along with the Bill No. Printed5. Detailed Hospital bill break-up for the expenses incurred.6. All original prescriptions & consultation papers of the Doctor.7. All original Medical bills with the name of the Patient duly endorsed by the treating Doctor.8. All original cash paid receipts supporting the bills in the name of patient vide receipt No:s.9. All original Medical reports certified by the Doctor (Pathology, X-Ray, CT-Scan, ECG, MRI,

etc.)10. Summary of all Expenses.11. Medico Legal Certificate (MLC) / FIR in case of accident cases.12. Medico Legal Certificate (MLC) & FIR both are mandatory in case of road traffic accident.13. All Indoor Case Papers (ICP).14. Cancelled cheque of the Employee along with Employee Name printed on Cheque leaf or

Bank Pass Book.

Checklist - Documents to be submitted for Re-imbursement


• Visit us at www.mdindiaonline.com

• Click on Login -- My Account Corporate Employee and

Click

15

Website Access - Online


http://www.mdindiaonline.com/

2/18/2016MDI Confidential Proprietary Information

Please provide your complete policy number / MD ID as on policy schedule

16

Login to your account


2/18/2016

Click on E card to download E card or on claims to see details of claims.

MDI Confidential Proprietary Information17

Welcome to primary information screen


Print E card as per your convenience if you require to give it to someone and

during claims submission .

18

E - Cards


2/18/2016 19

Android Phones – Mobile App

MDIndia Health Care Services ( TPA ) Pvt Ltd

2/18/2016 20

First Screen of the App –Click/Tap Corporate Policy Holder


2/18/2016 21

Enter the Valid Mobile Number, Verification code shall be sent to the Mobile number entered. This is one time registration process.


2/18/2016 22

Below details can be validated or obtained from employee individual login:1. E-Cards of Self &

Dependents.2. Claims Status –

Cashless &Reimbursement.

3. Policy Features andeligibility Criteria.

4. Network List ofHospitals for CashlessFacility across PanIndia.

5. Various formsavailable online


23

Provider Network – Our Network of Hospitals across Pan India

3Himachal Pradesh

Assam

Bihar

Andhra Pradesh

4

7

11

168

7

302

Haryana 100Punjab

Chandigarh

35

Uttarakhand 10

Uttar Pradesh

West BengalOrissa

Maharashtra

Gujarat

Rajasthan

Delhi

Madhya Pradesh

Goa

Karnataka

Kerala

Tamil Nadu

180

Chattisgarh

40

469

261

92

325

140

11

103

857

42

Daman & Diu 2

Jharkhand4

Meghalaya

16000+ HOSPITALS

EMPANELED &

GROWING.

*Visit website for latest list


Employee may contact MD India @ Toll Free & UAN Numbers –

• Cashless Hospitalization:

The Request for authorization(Cashless) form can be sent with the help of

network Hospital to the following No. or mail id.

1. Toll free Fax No -1860-233-4449.

2. Email - [email protected]

• Customer Care:

The Employee can contact the Customer Care on :-

1.Toll free No.- 1800-233-1166 or 1800-233-4505

2. Email - [email protected]

3. Online - www.mdindiaonline.com

Toll free No. and E-Mail ids –MDIndia Health Care Services (TPA) Pvt Ltd.

• 24 x 7 for 365

days at your

services

• Toll free numbers

for cashless

services and

customer queries.

• Supported with

Medical Query

Assistance round

the clock.


mailto:[email protected]


http://www.mdindiaonline.com/

• Contact Details:

Ms. Navara Renuka - 9391427060

Landline – : 040-23414121/ 040-23414125

Email - [email protected]

Point Of Contacts and Escalation Matrix –MDIndia Health Care Services (TPA) Pvt Ltd.


Escalation Level Name Contact No Mail ID

Level1 Ms. Navara Renuka 9391427060 [email protected]

Level2 Ms. Sangeetha Tammali 9390838023 [email protected]

Level3 Mr.Somasekhar Reddy 9347129606 [email protected]

Level4 Mr.Anand Rao Dasagiri 8886644260 [email protected];


MDIndia Health Care Services ( TPA ) Pvt Ltd 14 Jun’2015MDIndia Health Care Services ( TPA ) Pvt Ltd

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CLAIM FORM - PART A' to 'CLAIM FORM FOR HEALTH INSURANCE POLICIES OTHER THAN TRAVEL AND PERSONAL ACCIDENT - PART ATO BE FILLED BY THE INSURED

The issue of this Form is not to be taken as an admission of liablity

DETAILS OF PRIMARY INSURED:

a) Policy No.:

(To be Filled in block letters)S

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b) Sl. No/ Certificate no.

c) Company/ TPA ID No:

e) Address:

DETAILS OF INSURANCE HISTORY:

a) Currently covered by any other Mediclaim / Health Insurance: b) Date of commencement of first Insurance without break:

c) If yes, company name: Policy No.

Sum insured (Rs.) d) Have you been hospitalized in the last four years since inception of the contract?

Diagnosis: e) Previously covered by any other Mediclaim /Health insurance : :

Date: M M

Y

Y

Y

Y

f) If yes, company name:

DETAILS OF INSURED PERSON HOSPITALIZED: :

DETAILS OF HOSPITALIZATION: :

DETAILS OF CLAIM:

DETAILS OF BILLS ENCLOSED:

Sl. No. Bill No. Date Issued by Towards Amount (Rs)

DETAILS OF PRIMARY INSURED’S BANK ACCOUNT::

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2.

3.

4.

5.

6.

7.

8.

9.

10.

D YMD YM

D YMD YM

D YMD YM

D YMD YM

D YMD YM

D YMD YM

D YMD YM

D YMD YM

D YMD YM

City: State:

Pin Code Phone No: Email ID:

City: State:

Pin Code Phone No: Email ID:

D D

D D

M M

M M

Y Y

Y Y

Yes No

Yes No

Yes No

d) Name: S U R N A M E F I R S T N A M E M I D D L E N A M E

a) Name: S U R N A M E F I R S T N A M E M I D D L E N A M E

b) Gender Male Female c) Age years M M Y Y Y YMonths d) Date of Birth

e) Relationship to Primary insured: Self Spouse Child Father Mother Other (Please Specify)

(Please Specify)OtherRetiredStudentHome MakerSelf EmployedServicef) Occupation

g) Address (if diffrent from above) :

a) Name of Hospital where Admited:

b) Room Category occupied: Day care

D D M M Y Y H H H HM H M H

D D M M Y Y Y Y

D D M M Y Y

Single occupancy Twin sharing 3 or more beds per room

c) Hospitalization due to: Injury Illness Maternity d) Date of injury / Date Disease first detected /Date of Delivery:

e) Date of Admission: f) Time g) Date of Discharge: h) Time: :

NoYesI) If Medico legal

j) System of Medicine:

Substance Abuse / Alcohol ConsumptionI) If injury give cause: Self inflicted Road Traffic Accident

iii. MLC Report & Police FIR attachedii) Reported to Police NoYes

a) Details of the Treatment expenses claimed

I. Pre -hospitalization expenses

iii. Post-hospitalization expenses

v. Ambulance Charges:

Rs.

Rs.

Rs.

ii. Hospitalization expenses Rs.

iv. Health-Check up cost:

vi. Others (code):

Rs.

Rs.

Rs.Total

vii. Pre -hospitalization period: days viii. Post -hospitalization period: days

b) Claim for Domiciliary Hospitalization: NoYes (If yes, provide details in annexure)

c) Details of Lump sum / cash benefit claimed:

i. Hospital Daily cash: Rs.

Rs.

Rs.

iii. Critical Illness benefit:

v. Pre/Post hospitalization Lump sum benefit:

ii. Surgical Cash:

iv. Convalescence:

vi. Others:

Rs.

Rs.

Rs.

Rs.Total

Claim Documents Submitted - Check List:

Claim form duly signed

Copy of the claim intimation, if any

Hospital Main Bill

Hospital Break-up Bill

Hospital Bill Payment Receipt

Hospital Discharge Summary

Pharmacy Bill

Operation Theater Notes

ECG

Doctor’s request for investigation

Investigation Reports (Including CT/ MRI / USG / HPE)Doctor’s Prescriptions

Others

Hospital main Bill

Pharmacy Bills

Post-hospitalization Bills: Nos

Pre-hospitalization Bills: Nos

a) PAN:

c) Bank Name and Branch:

d) Cheque / DD Payable details:

b) Account Number:

e) IFSC Code:

(IMPORTANT: PLEASE TURN OVER)

DECLARATION BY THE INSURED:

I hereby declare that the information furnished in the claim form is true & correct to the best of my knowledge and belief. If I have made any false or untrue statement, suppressionor concealent of any material fact with respect to questions asked in relation to this claim, my right to claim reimbrusement shall be forfeited, I also consent & authorize TPA /Insurance Company, to seek necessary medical information / documents from any hospital / Medical Practitioner who has attended on the person against whom this claim is made.I hereby declare that I have included all the bills / receipts for the purpose of this claim & that I will not be making any supplementary claim except the pre/post-hospitalizationclaim, if any.

Date Y YD D M M Y Y Place: Signature of the Insured

GUIDANCE FOR FILLING CLAIM FORM - PART A (To be filled in by the insured)

DATA ELEMENT DESCRIPTION FORMAT

SECTION A - DETAILS OF PRIMARY INSURED

a) Policy No. Enter the policy number As allotted by the Insurance Company

b) Sl. No/ Certificate No.Enter the social Insurance number or the certificate number of

As allotted by the oraganizationsocial health insurance scheme

c) Company TPA ID No. Enter the TPA ID No.Licence number as allotted by IRDA and printedin TPA documents.

d) Name Enter the full name of the policyholder Surname, First name, Middle name

Include Street, City and Pin codeEnter the full postal addresse) Address

SECTION B -DETAILS OF INSURANCE HISTORY

a) Currently covered by any other Mediclaim / Health Insurance?

Indicate whether currently covered by another Mediclaim /Health Insurance

Tick Yes or No

b) Date of commencement of first Insurance without break Enter the date of commencement of first Insurance Use dd-mm-yy-forrmat

c) Company Name Enter the full name of the Insurance Company Name of the organization in full

Policy No. Enter the policy number As allotted by the Insurance Company

In rupeesEnter the total sum insured as per the policySum insured

d) Have you been Hospitalized in the last four years since Inception of the contract?

Indicate whether hospitalized in the last four years Tick Yes or No

Date Enter the date of Hospitalization Use mm-yy format

Diagnosis Enter the diagnosis details Open Text

Tick Yes or Noe) Previously covered by any other Mediclaim / Health Insurance?

Indicate whether previously covered by another mediclaim / Health Insurance

f) Company Name Enter the full name of the Insurance Company Name of the organization in full

SECTION C -DETAILS OF INSURED PERSON HOSPITALIZED

a) Name Enter the full name of the patient Surname, First name, Middle name

b) Gender Indicate Gender of the patient Tick Male or Female

c) Age Enter age of the patient Number of years and months

d) Date of Birth Enter Date of Birth of patient Use dd-mm-yy format

e) Relationship to primary Insured Indicate relationship of patient with policyholder Tick the right option, if others, please specify

f) Occupation indicate occupation of patient Tick the right option. If others, please specify.

g) Address Enter the full postal address Include Street, City and Pin code

Include STD code with telephone number

Complete e-mail address

h) Phone No

1) E-mail ID

Enter the phone number of patient

Enter e-mail address of patient

SECTION D - DETAILS OF HOSPITALIZATION

a) Name of Hospital where admited Enter the name of hospital Name of hospital in full

Tick the right option


Use dd-mm-yy format

Use dd-mm-yy format

Use hh-mm- format

Use dd-mm-yy format

Use hh-mm- format


Tick Yes or No

Tick Yes or No

Tick Yes or No

Open Text

b) Room category occupied

c) Hospitalization due to

d) Date of injury/Date Disease first detected / Date of Delivery

e) Date of admission

f) Time

g) Date of discharge

h) Time

I) If injury give cause

If Medico legal

Reported to Police

MLC Report & Police FIR attached

j) System of Medicene

indicate the room category occupied

indicate reason of hospitalization

Enter the relevant date

Enter date of admission

Enter time of admission

Enter date of discharge

Enter time of discharge

indicate cause of injury

indicate whether injury is medico legal

indicate whether police report was filed

indicate whether MLC report and Police FIR attached

Enter the system of medicine followed in treating the patient

SECTION E - DETAILS OF CLAIM

a) Details of Treatment Expences

b) Claim for Domiciliary Hospitalization

c) Details of Lump sum/ Cash benifit claimed

d) Claim documents Submitted-Check List

Enter the amount claimed as treatment expences

indicate whether claim is for domiciliary hospitalization

Enter the amount claimed as lump sum / cash benefit

indicate which supporting documents are submitted

Tick Yes or No


In rupees (Do not enter paise values)


SECTION F - DETAILS OF BILLS ENCLOSED

Indicate which bills are enclosed with the amount in rupees

SECTION G - DETAILS OF PRIMARY INSURED’s BANK ACCOUNT

a) PAN

b) Account Number

c) Bank Name and Branch

c) Cheque/ DD payable details

c) IFSC Code

Enter the permanent account number

Enter the Bank account number

Enter the Bank name along with the branch

Enter the name of the beneficiary the cheque / DD should bemade out to

Enter the IFSC code of the Bank branch

As allotted by the Income Tax Department

As allotted by the Bank

Name of the Bank in full

Name of the individual / organization in full

IFSC code of the Bank branch in full

SECTION H - DECLARATION BY THE INSURED

Read declaration carefully and mention date (in dd:mm:yy format), place (open text) and sign.

SE

CT

ION

H

CLAIM FORM - PART BTO BE FILLED IN BY THE HOSPITAL

The issue of this Form is not to be taken as an admission of liabilityPlease include the original preauthorization request form in lieu of PART A

(To be Filled in block letters)

DETAILS OF HOSPITAL

a) Name of the hospital:

a) Hospital ID:

c) Name of the treating doctor:

e) Qualification:

DETAILS OF THE PATIENT ADMITTED

c) Type of Hospital: Network : Non Network : (if non network fill section E)

f) Registration No. with State Code: g) Phone No.

a) Name of the Patient:

b) IP Registration Number: c) Gender: Male Female d) Age: Years Months e) Date of birth:

ii) Gravida Status: :

m) Total claimed amount

h) Date of Discharge:

i) Date of Delivery: k) If MaternityMaternityDay CarePlannedEmergency

f) Date of Admission:

j) Type of Admission:

I) Status at time of discharge: Discharge to home Discharge to another hospital Deceased

DETAILS OF AILMENT DIAGNOSED (PRIMARY)

a) ICD 10 Codes

I. Primary Diagnosis

ii. Additional Diagnosis:

iii. Co-morbidities:

iv. Co-morbidities:

vi. If not reported to police give reason:

Description b)

i. Procedure 1:

ii. Procedure 2:

iii. Procedure 3:

iv. Details of Procedure:

ICD 10 PCS Description

c) Pre-authorization obtained: Yes

Yes

Yes Yes

No

No

No No

d) Pre-authorization Number:

e) If authorization by network hospital not obtained, give reason:

f) Hospitalization due to injury: I. If Yes, give cause Self-inflicted Road Traffic Accident Substance abuse / alcohol consumption

iv. Reported to Policeiii. If Medico legal:(If Yes, attach reports)ii) If injury due to substance abuse / alcohol consumption, Test conducted to establish this:

v. FIR No.

CLAIM DOCUMENTS SUBMITTED - CHECK LIST

Claim Form duly signed

Original Pre-authorization request

Copy of the Pre-authorization approval letter

Copy of Photo ID Card of patient Verified by hospital

Hospital Discharge summary

Operation Theatre Notes

Hospital main bill

Hospital break-up bill

Investigation reports

CT/MR/USG/HPE investigation reports

Doctor’s reference slip for investigation

ECG

Pharmacy bills

MLC reports & Police FIR

Original death summary from hospital where applicable

Any other, please specify

ADDITIONAL DETAILS IN CASE OF NON NETWORK HOSPITAL (ONLY FILL IN CASE OF NON-NETWORK HOSPITAL)

(PLEASE READ VERY CAREFULLY)

a) Address of the Hospital

d) Hospital PAN:

iii. Others:

DECLARATION BY THE HOSPITAL

We hereby declare that the information furnished in this Claim Form is true & correct to the best of our knowledge and belief. If we have made any false or untrue statement, suppression or concealment of any material fact,our right to claim under this claim shall be forfeited.

Date:

Place: Signature and Seal of the Hospital Authority:

SE

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AS

EC

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N B

SE

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CS

EC

TIO

N D

SE

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ES

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N F

Yes No

Yes No

City: State:

Pin Code: b) Phone No. c) Registration No. with State Code:

e) Number of inpatient beds f) Facilities available in the hospital i. OT ii. ICU Yes No

S U R N A M E F I R S T N A M E M I D D L E N A M E

S U R N A M E F I R S T N A M E M I D D L E N A M E

D D M M Y Y H H M M

Y Y M M

M M

M M

D D

D D

H MH MY

Y

D D M M Y Y

D D M M Y Y

Y

Y

g) Time:

GUIDANCE FOR FILLING CLAIM FORM - PART B (To be filled in by the hospital)

DATA ELEMENT DESCRIPTION FORMAT

a) Name of the hospital:

b) Hospital ID

c) Type of Hospital

c) Name of treating doctor

SECTION A - DETAILS OF HOSPITAL

e) Qualification

f) Registration No. with State Code

g) Phone No.

Enter the name of hospital

Enter ID number of hospital

Indicate whether in network or non network hospital

Enter the name of the treating doctor

Enter the qualification of the treating doctor

Enter the registration number of the doctor along with the state code

Enter the phone number of doctor

SECTION B - DETAILS OF THE PATIENT ADMITTED

a) Name of Patient

b) IP registration Number

c) Gender

d) Age

e) Date of Birth

f) Date of Admission

g) Time

h) Date of Discharge

i) Time

j) Type of Admission

k) If Maternity

Date of Delivery

Gravida Status

l) Status at time of discharge

M) Total claimed amount

Enter the name of patient

Enter insurance provider registration number

Indicate Gender of the patient

Enter age of the patient

Enter date of birth

Enter date of admission

Enter Time of admission

Enter date of Discharge

Enter time of Discharge

Indicate type of admission of patient

Enter Date of Delivery if maternity

Enter Gravida status if maternity

Indicate status of patient at time of discharge

Indicate the total claimed amount

SECTION C - DETAILS OF AILMENT DIAGNOSED (PRIMARY)

a) ICD 10 Code

Primary Diagnosis

Additional Diagnosis

Co-morbidities

b) ICD 10 PCS

Procedure 1

Procedure 2

Procedure 3

Details of Procedure

c) Pre-authorization obtained

d) Pre-authorization Number

e) If authorization by network hospital not obtained, give reason

f) Hospitalization due to injury

Cause

If injury due to substance abuse/alcohol consumption test conducted to establish this

Medico Legal

Reported to Police

FIR No.

If not reported to police, give reason

Indicate which supporting documents are submitted

SECTION D - CLAIM DOCUMENTS SUBMITTED-CHECK LIST

SECTION E - DETAILS IN CASE OF NON NETWORK HOSPITAL

a) Address

b) Phone No.

c) Registration No. with State Code

d) Hospital PAN

e) Number of Inpatient beds

f) Facilities available in the hospital

Read declaration carefully and mention date (in dd:mm:yy format), place (open text) and sign. and stamp

Enter the ICD 10 Code and description of the primary diagnosis

Enter the ICD 10 Code and description of the additional diagnosis

Enter the ICD 10 Code and description of the Co-morbidities

Enter the ICD 10 Code and description of the first procedure

Enter the ICD 10 Code and description of the second procedure

Enter the ICD 10 Code and description of the third procedure

Enter the details of the procedure

Enter pre-authorization number

Indicate whether pre-authorization obtained

Enter reason for not obtaining pre-authorization number

Indicate if hospitalization is due to injury

Indicate cause of injury

Indicate whether test conducted

Indicate whether injury is medico legal

Indicate whether police report was filed

Enter first information report number

Enter reason for not reporting to police

Enter the full postal address

Enter the phone number of hospital

Enter the permanent account number

Enter the number of inpatient beds

Indicate facilities available in the hospital

SECTION F - DECLARATION BY THE HOSPITAL

Name of the hospital in full

As allocated by the TPA


Name of doctor in full

Abbreviations of educational qualifications

As allocated by the Medical Council of India


Name of patient in full

As allotted by the insurance provider

Tick Male or Female

Number of years and months

Use dd-mm-yy format

Use dd-mm-yy format

Use hh:mm format

Use dd-mm-yy format

Use hh:mm format


Use dd-mm-yy format

Use standard format



Include Street, City and Pin Code


As allocated by the City Corporation / Municipality

As allocated by the Income Tax Department

Digits

Tick the right option. If others, please specify

Standard Format and Open text






Open text

Tick Yes or No

As allotted by TPA

Open text

Tick Yes or No

Tick Yes or No


Tick Yes or No

Tick Yes or No

As issued by police authrities

Open text

Enter the registration number of the Hospital obtained from local bodylike City Corporation / Municipality